Failure to Implement Person-Centered Fall Prevention Care Plan
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan for a resident with a history of falls and significant medical conditions, including traumatic subarachnoid hemorrhage, hemiplegia, and convulsions. After the resident experienced a fall resulting in a hip fracture, a care plan conference was held with the resident, family, and facility staff, where specific interventions were agreed upon, such as a therapy evaluation for wheelchair safety, dropping the wheelchair seat, and adding non-skid material to the wheelchair. These interventions were documented in the care plan but were not carried out as intended. Interviews and record reviews revealed that the therapy evaluation was not completed due to the resident's private pay status and lack of funding approval, and the wheelchair seat was not dropped nor was non-skid material added. Staff members, including the LVN and MDS Coordinator, confirmed that these interventions were not implemented, and the MDS Coordinator was unsure how these care plan items were missed. The DON stated that a restorative nursing plan was initiated after the resident returned from the hospital, but the specific interventions discussed in the care plan meeting were not provided prior to the resident's hospitalization. The administrator acknowledged the importance of following care plan interventions decided by the interdisciplinary team but confirmed that the therapy evaluation and related safety interventions were not completed before the resident's hospital transfer. The facility's own policy requires the development and implementation of a comprehensive care plan with measurable objectives and timeframes to meet each resident's needs, but this was not followed in this case.